Application Form

Promotion and Development of Healthcare in Southern Africa

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The following section to be filled in by current SAFHE members only:
Current SAFHE member:
Date of first membership: (Year only if membership date is not known)
Place of first membership: (current or original region or branch name)
Place of current membership:
The following section to be filled in by all current and prospective SAFHE members:
Contact Information:
Surname:
Initials:
First Name:
Title:
Postal Address:
Telephone (H):
Telephone (W):
Cellular Number:
Fax number:
e-mail address:
Professional Information
Discipline / occupation:
Professional qualification/s:
Company:
Company Address:
Company web site URL:
Experience in the healthcare field related to the aims and objectives of SAFHE:
Membership of other professional organisations:
Proposer / Seconder
Current SAFHE members of good standing supporting membership application
Proposer Name:
Proposer Occupation:
Seconder Name:
Seconder Occupation:
Expertise Register
Include your name in the expertise register? (R500 listing fee is payable annually)
Profession:
Field of expertise: